Provider Demographics
NPI:1902954332
Name:JACKSONVILLE ORTHOPAEDIC INSTITUTE INC
Entity Type:Organization
Organization Name:JACKSONVILLE ORTHOPAEDIC INSTITUTE INC
Other - Org Name:JACKSONVILLE ORTHOPAEDIC INSTITUTE REHABILITATION
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ATC
Authorized Official - Phone:904-858-7045
Mailing Address - Street 1:PO BOX 117345
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7345
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6489
Practice Address - Street 1:1577 ROBERTS DR
Practice Address - Street 2:SUITE 320
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3264
Practice Address - Country:US
Practice Address - Phone:904-247-3324
Practice Address - Fax:904-247-3926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X
FLAL3512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24314Medicare PIN